Performance and Image Enhancing Drugs John Campbell

Presentation Overview Reasons for use How Steroids work Common Steroids How they are taken Risks Harms Reducing harm PCT The Law

Prevalence and Trends Poor UK survey Data Small area or location studies Glasgow accurate NEO data

Steroid use 'on par with heroin' 2007 Steroid use may be more than twice as common as official figures suggest, a leading expert has told the BBC. According to the British Crime Survey there are 42,000 regular anabolic steroid users in the UK. Drugs expert Jim McVeigh said there could be as many as 100,000. "Basically we're looking at numbers being on a par with heroin users," he added. One treatment centre in Merseyside reports that steroid use has rocketed in the last three years. Staff now treat four new steroid users for every new heroin user - a reversal of the situation in 2004. There is a particular problem with users aged under 25.

Drugs injected at registration – all sites 2012 -2013

New Registrations GDCC 2012 – 2013 (drugs injected)         New Registrations GDCC 2012 – 2013 (drugs injected)

Glasgow’s PIEDs Clinic Established in 2009 Drop in service – 1 evening per week Staffed by 2 workers and nurse ( supported by lead medical officer) Based in the GDCC and supported by Turning Point

Aim Of Clinic To provide a specialised and accessible service. To raise the awareness of the risk of BBV (Blood borne virus) and related infections. To identify ‘other’ harms and complications Provide alternatives to PIEDs use To improve injecting techniques To direct individuals to their local pharmacy needle exchanges for future transactions.

Letting clients know about the service successful unsuccessful Referrals from other exchanges Gym buddies Dealers Forums Gym owners Supplement Stores Poster displays

What we offer Needles and paraphernalia provision, including water for injection. Consultations/assessments Discussions on; ‘harmful’ doses, understanding ‘labels’ and syringe markings Safer injecting advice and demonstrations Alternatives such as diet and exercise Wound identification Product identification Blood tests

Date Collected HIV NEG HEP B HEP C Test Declined No Abnormal U&E Yes Abnormal LFT Abnormal Cholestrol Abnormal Hormones Repeat Test

PIED using groups Image enhancing Athletic/sports Non-athletic training Occupational Dysmorphia/self esteem

Comparison with Street Drugs Similarities differences Stigma Method of administration Poly drug use How bought Dependency Self perception How bought Legality Self welfare Social status? Ratio of men to women No instant gratification

Anabolic/Androgenic Steroids (AAS) They are synthetically produced variants of the naturally occurring male sex hormone testosterone. “Anabolic” refers to muscle- building, and “androgenic” refers to increased male sexual characteristics. “Steroids” refers to the class of drugs. These drugs can be legally prescribed to treat conditions resulting from steroid hormone deficiency, such as delayed puberty, as well as diseases that result in loss of lean muscle mass, such as cancer and AIDS.

How Steroids work

Natural Test production HYPOTHALAMUS GnRH PITUITARY LH FSH TESTES Testosterone

Common Substances Anabolic/Androgenic steroids : to increase bulk, strength and power Oestrogen-blockers: to block symptoms of feminisation Diuretics: to remove excess water Fat-burners: to remove excess fat and “cut up” Growth Enhancers: to promote new cell growth Post-cycle treatments: to stimulate natural testosterone production Injectable tanning agents: to stimulate pigmentation

Commonly used steroids Injectables (commercial and street names) Sustanon 250/Omnadren (sust) Testosterone Cypionate (cyp) Testosterone Enanthate (test) Testosterone Propionate (prop) Trenbolone (tren) Nandrolone (Deca Durabolin deca) Stanozolol solution (Winstrol winny) Methenolone (primobolan primo) Boldenone (equipoise) Various blends emerging

Oral Steroids Testosterone Undecanoate (andriol) Oxymetholone (Anadrol/oxies) Oxandrolone (oxandrin - Anavar) Methandrostenolone (Dianabol d-bol) Stanozolol tablets (Winstrol winny) ORAL STEROIDS CAN BE MORE HARMFUL THAN INJECTABLES

Types of steroids produced Pharmaceutical grade Good quality but often low in strength and amounts Underground May be poor quality/unsterile often high concentrations Veterinarian Not designed for human use Counterfeit Often contain no active product and may be unsafe

Recent example of counterfeit

Human Chorionic Gonadotrophin Other substances Miscellaneous Human Growth Hormone GHRP 2 & 6 CJC 1295 LR3 IGF -1 Insulin Melanotan 1&2 Fat Burners Ephedrine Clenbuterol T3 T4 ECA stack Anti-estrogen & PCT Human Chorionic Gonadotrophin Nolvadex (tamoxifen) Clomid Citrate Arimidex Letrozole Viagra

hGH hGH (and the IGF-1 that is a result of its use) is the only substance that can actually initiate hyperplasia (new cells). GH is produced by the pituitary, IGF-1 is produced primarily by the liver in response to GH It requires careful storage, handling and preparation Many newer peptides also work in a similar way

Melanotan 2 Melanotan is a hormone that stimulates melanin production Other reported benefits: weight loss increased libido healthy spot free skin

Patterns of Use Stacking: taking several different steroids at the same time Cycling: taking multiple doses over a period of weeks or months, stopping, then starting again. Pyramiding: slowly increasing amount of steroids taken over 6- 12wks, then decreasing the amount slowly ‘Addictive’ behavioural patterns are easily identifiable

Sample stack and cycle Cost £200 Cost £200 Cost £50 Cost £45

Cost £320 Cost £80 Cost £160 Cost £100 Cost £1000 Cost £70

What happens after the cycle finishes? After the cycle comes the crash The body enters a ‘catabolic’ state Testes become de-sensitised FSH and LH are not produced/released Estrogen level rise Lethargy and low mood can set in

8 Week Cycle

Anabolic Steroid Induced Hypogonadism- Dr Scally “An unproven and unfounded assumption has been made in the medical establishment that the treatment for an individual suffering from ASIH is to do nothing which is coined ‘watchful waiting’ and in time HPTA functioning will return to normal” Doctors appear to be treating the symptoms of low test, not the cause

Post Cycle Therapy Idea is to accelerate and restore the body’s endogenous test production There are many different views on how this can be achieved However, most involve the same drugs………..

Post Cycle Therapy – Rationale shocks the testicles into action - increasing testicular mass HCG Nolvadex blocks negative feedback from too much estrogen Clomid stimulates the hypothalamus HYPOTHALAMUS GnRH PITUITARY LH FSH TESTES Testosterone

HARMS

Risks - Adolescents One of the most detrimental thing that could happen is the stunting of growth plates Other complications involve extreme bone pain, liver toxicity, vascular damage, kidney damage, and joint problems

Risks - Women Changes in the reproductive system Birth defects (virilisation of female foetus) Development of a more masculine physique, shrinkage of the breast tissue, deepening of the voice, male pattern baldness and coarse skin.

Risks - Men Shrinking of the testicles - temporary Reduced sperm count - infertility Sexual dysfunction Prostate enlargement Baldness Gynaecomastia - development of breasts

Risks All Increases in LDL (bad cholesterol) and decreases in HDL (good cholesterol) Modification in the left ventricle of the heart, with serious implications Increased risk of developing heart related complications/stroke Acne High Blood Pressure Mood swings Jaundice/liver damage Pain in the joints (esp with Winny or hGH) Urinary problems

Steroid Dependence Fact or Fiction? DSM IV - Drug dependency occurs if: The drug is taken higher doses or for longer than intended Unsuccessful efforts to stop or cut down Excessive time spent obtaining or using the substance Important activities are given up Continued use despite negative health effects Need for higher amounts to be taken for the desired effect Withdrawal symptoms occur

PIED Dependance If people are “addicted” to using these substances what interventions may help? Do we work with PIEDs users in the same way as we would other drug users? If we need to change our approach how do we do this?

Addiction, Dependence and treatment? Talking therapies Continued use due to fear of muscle loss – CBT Dealing with steroid cravings – Relapse Prevention Unwillingness to stop - MI Medical interventions Depression post cycle – antidepressants Loss of sexual function - Viagra Hypogonadism – HCG & Clomid

Harm Reduction Advice Use reasonable dosages and stacks Always cycle Use only the safest drugs Use testosterone as a first choice? Avoid toxic oral steroids Avoid counterfeit and underground Always consider risk and reward Use proper injecting tech Get regular blood tests Use reasonable dosages and stacks